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More than 50 injured by bombs still in Boston hospitals
Fifty-one runners and spectators remained hospitalized April 23 with injuries from the Boston Marathon bombings, according to the Boston Public Health Commission.
With a total of 264 patients treated at Boston area hospitals, "the team approach [was] vital," said Dr. Jeffrey Kalish, director of endovascular surgery at Boston Medical Center. "These types of injuries require multiple teams talking together and working together. It taught us really how to work together across multiple disciplines in a really acute time frame."
At BMC, "the initial approach was gathering every single surgeon available and figuring out who could do which specific operations," Dr. Kalish said.
"On the first day, the goal was to get the patients in and out of the operating room and stop the bleeding," he said. The next day [Tuesday], "we got together as a big group and talked about every patient and decided who was going to take over their care."
Teams met twice a day and while the surgeons focused on the patients, the hospital leadership made sure that adequate staff and infrastructure were available.
"This [experience] really taught me the importance of practicing for the unthinkable and practicing for the unknown, so when these things happen, it’s not as much of a surprise," said Dr. Kalish. "Talking about command structure and incident reporting and how to deploy the resources to the best of hospital’s knowledge is a very worthwhile thing."
Five patients at BMC have had above- or below-the-knee amputations and have averaged at least two surgical procedures each. One patient has had five.
For those with amputations, wound healing and pain control are now the most important factors, according to Dr. Simona Manasian, a rehabilitation medicine physician at BMC. Once the wounds are healed, the focus turns to shaping the stumps for prostheses.
Patients have begun early rehabilitation and physical therapy to strengthen the lower limbs and their upper bodies for mobility and support.
Patients also have been receiving psychological support, Dr. Manasian said. She added that they have been visited by several veterans who were similarly injured in Iraq or Afghanistan and who are farther along in adapting to amputations and prostheses. "That was very helpful."
Dr. Kalish added, "We’ve seen a full range of emotions over the past week. But now that we’re a week into this, everyone’s emotionally doing much better. [The patients are] optimistic, and they know that life will be a little different, but life is not over."
On Twitter @NaseemSMiller
Fifty-one runners and spectators remained hospitalized April 23 with injuries from the Boston Marathon bombings, according to the Boston Public Health Commission.
With a total of 264 patients treated at Boston area hospitals, "the team approach [was] vital," said Dr. Jeffrey Kalish, director of endovascular surgery at Boston Medical Center. "These types of injuries require multiple teams talking together and working together. It taught us really how to work together across multiple disciplines in a really acute time frame."
At BMC, "the initial approach was gathering every single surgeon available and figuring out who could do which specific operations," Dr. Kalish said.
"On the first day, the goal was to get the patients in and out of the operating room and stop the bleeding," he said. The next day [Tuesday], "we got together as a big group and talked about every patient and decided who was going to take over their care."
Teams met twice a day and while the surgeons focused on the patients, the hospital leadership made sure that adequate staff and infrastructure were available.
"This [experience] really taught me the importance of practicing for the unthinkable and practicing for the unknown, so when these things happen, it’s not as much of a surprise," said Dr. Kalish. "Talking about command structure and incident reporting and how to deploy the resources to the best of hospital’s knowledge is a very worthwhile thing."
Five patients at BMC have had above- or below-the-knee amputations and have averaged at least two surgical procedures each. One patient has had five.
For those with amputations, wound healing and pain control are now the most important factors, according to Dr. Simona Manasian, a rehabilitation medicine physician at BMC. Once the wounds are healed, the focus turns to shaping the stumps for prostheses.
Patients have begun early rehabilitation and physical therapy to strengthen the lower limbs and their upper bodies for mobility and support.
Patients also have been receiving psychological support, Dr. Manasian said. She added that they have been visited by several veterans who were similarly injured in Iraq or Afghanistan and who are farther along in adapting to amputations and prostheses. "That was very helpful."
Dr. Kalish added, "We’ve seen a full range of emotions over the past week. But now that we’re a week into this, everyone’s emotionally doing much better. [The patients are] optimistic, and they know that life will be a little different, but life is not over."
On Twitter @NaseemSMiller
Fifty-one runners and spectators remained hospitalized April 23 with injuries from the Boston Marathon bombings, according to the Boston Public Health Commission.
With a total of 264 patients treated at Boston area hospitals, "the team approach [was] vital," said Dr. Jeffrey Kalish, director of endovascular surgery at Boston Medical Center. "These types of injuries require multiple teams talking together and working together. It taught us really how to work together across multiple disciplines in a really acute time frame."
At BMC, "the initial approach was gathering every single surgeon available and figuring out who could do which specific operations," Dr. Kalish said.
"On the first day, the goal was to get the patients in and out of the operating room and stop the bleeding," he said. The next day [Tuesday], "we got together as a big group and talked about every patient and decided who was going to take over their care."
Teams met twice a day and while the surgeons focused on the patients, the hospital leadership made sure that adequate staff and infrastructure were available.
"This [experience] really taught me the importance of practicing for the unthinkable and practicing for the unknown, so when these things happen, it’s not as much of a surprise," said Dr. Kalish. "Talking about command structure and incident reporting and how to deploy the resources to the best of hospital’s knowledge is a very worthwhile thing."
Five patients at BMC have had above- or below-the-knee amputations and have averaged at least two surgical procedures each. One patient has had five.
For those with amputations, wound healing and pain control are now the most important factors, according to Dr. Simona Manasian, a rehabilitation medicine physician at BMC. Once the wounds are healed, the focus turns to shaping the stumps for prostheses.
Patients have begun early rehabilitation and physical therapy to strengthen the lower limbs and their upper bodies for mobility and support.
Patients also have been receiving psychological support, Dr. Manasian said. She added that they have been visited by several veterans who were similarly injured in Iraq or Afghanistan and who are farther along in adapting to amputations and prostheses. "That was very helpful."
Dr. Kalish added, "We’ve seen a full range of emotions over the past week. But now that we’re a week into this, everyone’s emotionally doing much better. [The patients are] optimistic, and they know that life will be a little different, but life is not over."
On Twitter @NaseemSMiller
DEA bans 'bath salt' chemical
One of the main chemicals in synthetic stimulants sold as "bath salts" or "plant food" is now a Schedule I drug, the Drug Enforcement Administration has announced.
The ruling permanently places methylone (3,4-methylenedioxy-N-methylcathinone) in the most restrictive category created by the Controlled Substance Act; Schedule I is reserved for unsafe and highly abused substances with no accepted medical use.
The agency first put methylone on emergency scheduling in 2011 while studying whether the chemical should be permanently controlled. In a related effort, the agency also issued a Notice of Intent to temporarily control three synthetic cannabinoids (UR-144, XLR11, and AKB48) that are falsely marketed as "herbal incense."
"This action will become effective upon publishing a Final Order to temporarily control these substances as Schedule I substances for up to 2 years, with the possibility of a 1-year extension," according to a DEA news release.
Designer drugs like bath salts have become a public health concern in recent years. The substances are popular among some young adults and teens, especially since they are obtained easily in certain stores and hookah bars.
Officials first became aware of the new intoxicants when poison control centers began receiving calls from emergency departments and physicians who could not identify the substance affecting their paranoid, and sometimes violent, patients.
The effects of bath salts are similar to those of cocaine, LSD, and methamphetamine – increased heart rate and blood pressure, as well as hallucinations. Users also can experience extreme paranoia and violent behavior leading to self-harm or harm of others, according to the Office of National Drug Policy Control (ONDCP).
When it comes to synthetic marijuana, the effects include agitation, extreme nervousness, nausea, vomiting, tachycardia, elevated blood pressure, tremors and seizures, hallucinations, and dilated pupils, according to ONDCP.
Although there’s no antidote to these designer drugs, physicians recommend screening for them. The long-term effects of the drugs are not known but are potentially severe. Use of these drugs has led to dozens of deaths.
In 2010, poison control centers received 2,906 calls relating to human exposure to synthetic marijuana, according to the American Association of Poison Control Centers. That number more than doubled to 6,959 in 2011 but then dropped to 2,655 in 2012, partly due to the emergency ban that the DEA put on the substances in late 2011. As of the end of this March, there had been 254 calls to poison control centers.
On Twitter @NaseemSMiller
One of the main chemicals in synthetic stimulants sold as "bath salts" or "plant food" is now a Schedule I drug, the Drug Enforcement Administration has announced.
The ruling permanently places methylone (3,4-methylenedioxy-N-methylcathinone) in the most restrictive category created by the Controlled Substance Act; Schedule I is reserved for unsafe and highly abused substances with no accepted medical use.
The agency first put methylone on emergency scheduling in 2011 while studying whether the chemical should be permanently controlled. In a related effort, the agency also issued a Notice of Intent to temporarily control three synthetic cannabinoids (UR-144, XLR11, and AKB48) that are falsely marketed as "herbal incense."
"This action will become effective upon publishing a Final Order to temporarily control these substances as Schedule I substances for up to 2 years, with the possibility of a 1-year extension," according to a DEA news release.
Designer drugs like bath salts have become a public health concern in recent years. The substances are popular among some young adults and teens, especially since they are obtained easily in certain stores and hookah bars.
Officials first became aware of the new intoxicants when poison control centers began receiving calls from emergency departments and physicians who could not identify the substance affecting their paranoid, and sometimes violent, patients.
The effects of bath salts are similar to those of cocaine, LSD, and methamphetamine – increased heart rate and blood pressure, as well as hallucinations. Users also can experience extreme paranoia and violent behavior leading to self-harm or harm of others, according to the Office of National Drug Policy Control (ONDCP).
When it comes to synthetic marijuana, the effects include agitation, extreme nervousness, nausea, vomiting, tachycardia, elevated blood pressure, tremors and seizures, hallucinations, and dilated pupils, according to ONDCP.
Although there’s no antidote to these designer drugs, physicians recommend screening for them. The long-term effects of the drugs are not known but are potentially severe. Use of these drugs has led to dozens of deaths.
In 2010, poison control centers received 2,906 calls relating to human exposure to synthetic marijuana, according to the American Association of Poison Control Centers. That number more than doubled to 6,959 in 2011 but then dropped to 2,655 in 2012, partly due to the emergency ban that the DEA put on the substances in late 2011. As of the end of this March, there had been 254 calls to poison control centers.
On Twitter @NaseemSMiller
One of the main chemicals in synthetic stimulants sold as "bath salts" or "plant food" is now a Schedule I drug, the Drug Enforcement Administration has announced.
The ruling permanently places methylone (3,4-methylenedioxy-N-methylcathinone) in the most restrictive category created by the Controlled Substance Act; Schedule I is reserved for unsafe and highly abused substances with no accepted medical use.
The agency first put methylone on emergency scheduling in 2011 while studying whether the chemical should be permanently controlled. In a related effort, the agency also issued a Notice of Intent to temporarily control three synthetic cannabinoids (UR-144, XLR11, and AKB48) that are falsely marketed as "herbal incense."
"This action will become effective upon publishing a Final Order to temporarily control these substances as Schedule I substances for up to 2 years, with the possibility of a 1-year extension," according to a DEA news release.
Designer drugs like bath salts have become a public health concern in recent years. The substances are popular among some young adults and teens, especially since they are obtained easily in certain stores and hookah bars.
Officials first became aware of the new intoxicants when poison control centers began receiving calls from emergency departments and physicians who could not identify the substance affecting their paranoid, and sometimes violent, patients.
The effects of bath salts are similar to those of cocaine, LSD, and methamphetamine – increased heart rate and blood pressure, as well as hallucinations. Users also can experience extreme paranoia and violent behavior leading to self-harm or harm of others, according to the Office of National Drug Policy Control (ONDCP).
When it comes to synthetic marijuana, the effects include agitation, extreme nervousness, nausea, vomiting, tachycardia, elevated blood pressure, tremors and seizures, hallucinations, and dilated pupils, according to ONDCP.
Although there’s no antidote to these designer drugs, physicians recommend screening for them. The long-term effects of the drugs are not known but are potentially severe. Use of these drugs has led to dozens of deaths.
In 2010, poison control centers received 2,906 calls relating to human exposure to synthetic marijuana, according to the American Association of Poison Control Centers. That number more than doubled to 6,959 in 2011 but then dropped to 2,655 in 2012, partly due to the emergency ban that the DEA put on the substances in late 2011. As of the end of this March, there had been 254 calls to poison control centers.
On Twitter @NaseemSMiller
Emergency physicians share lessons from Boston Marathon bombings response
If there’s one piece of advice that Boston emergency physicians have for their peers following the Boston Marathon bombings, it’s this: drill, drill, drill.
"No matter how much drilling you do, you will never really prepare yourself for what this is like," said Dr. Ron M. Walls, chairman of the department of emergency medicine at Brigham and Women’s Hospital.
"But I would encourage everyone to plan those drills, take them seriously, do them well, and do them often. There’s no question that the expertise of emergency physicians and surgeons and nurses is crucial at the time of response, but being part of the systematic response and knowing that you’re part of systematic response is also very important."
On Monday afternoon, April 15, before the two improvised explosive devices detonated near the finish line of the Boston Marathon, killing three and injuring more than 170 people, Dr. Walls was in his office with his department administrator going over the budget. Suddenly, an alert went through the phone system. A news banner popped up on his phone.
"And then I heard an absolute cacophony of sirens, more than I had ever heard anywhere," he said in an interview.
Boston is unique when it comes to emergency and trauma care. It has five level 1 trauma centers. And Massachusetts was one of the first states to ban ambulance diversions in 2009. As a result, hospitals have created protocols to move patients quickly and make room in the ED.
"EMS [emergency medical services] did a beautiful job of distributing the patients at Beth Israel Deaconess Medical Center. There wasn’t any point where we felt truly overwhelmed," said Dr. Richard E. Wolfe, chief of emergency medicine at the medical center.
And the drills and preparations helped. While mass casualty drills have been a part of hospital operations for years, the 9/11 terrorist attacks brought the importance of preparation to the forefront.
"We’ve had a big shift in education," said Col. John McManus, MC, USA (ret.), an emergency physician who was among the last to leave Iraq in 2011. "Even though we learned a lot of these lessons from World War II and Vietnam, we kind of forgot about some of it. They were published, but we didn’t keep them in the cutting edge of medicine. We felt like it was never going to happen here, and that the military had to deal with it. After 9/11, unfortunately, we realized that we were underprepared and undertrained to treat these kinds of casualties."
Brigham and Women’s Hospital has held 73 disaster preparation drills since 2006, including citywide drills with Boston EMS, Dr. Walls said.
Now, the many hospitals have physicians, nurses, and other personnel on staff who have served in combat situations. Federal agencies, medical societies, and private entities are collaborating to update training and medical information. "The majority of scientific meetings include military and blast education," Dr. McManus, vice president of medical affairs at Masimo Corporation, said in an interview.
"What’s happened since Sept. 11 is that people are much more focused on disaster management and mass casualty events," Dr. Wolfe said in an interview. At Beth Israel Deaconess Medical Center, "we’ve had speakers from Israel doing visiting fellowships with us. We had Dr. Chris Caldwell, who helped coordinate the Aurora and Columbine disaster responses, as a visiting professor with us, walking us through the lessons learned in Columbine.
"It’s become part of residency training and didactic programs, and has really developed a culture of knowledge in terms of mass casualty events, in a way that we didn’t have in the 80s and 90s," Dr. Wolfe said.
And after each disaster, be it Hurricane Katrina or the Boston Marathon, hospitals improve their protocols and share what they’ve learned. Both Dr. Walls and Dr. Wolfe said they wanted to improve communication, whether it’s within the hospital and between the departments, or whether it’s with outside staff who may feel left out of the loop.
On Monday afternoon, Dr. Wolfe had just gotten home when he saw television reports of the bombing. He called his ED and headed back to work. Within minutes, ED personnel levels increased fivefold as patients began to arrive.
He quickly established crowd control in the ED, and put some of the volunteers on the reserve and on the sidelines. He also created zones, where people worked in small pockets. There was a disaster coordinator on the scene "so we had all the right people," Dr. Wolfe said.
Out front, social workers dealt with others who were arriving at the hospital. Registration was "very focused on getting real names so that we wouldn’t lose any patients to mistaken identity," he said. Patients were quickly assessed as they arrived, then flowed rapidly to the next stage of care, whether it was operating room or intensive care."
At Brigham and Women’s, the emergency department received a total of 35 patients, 28 of whom arrived in an hour.
"When this started, we had a pretty full ED," said Dr. Walls, professor of medicine at Harvard Medical School. "We decompressed by moving some of the patients out of the ED or into inpatient units. We created a lot of capacity in a short period of time. At the same time, we had alerted the OR, and it happened to be shift change, so we froze the staff, resulting in double staffing. And it was Monday afternoon on a holiday, so the ORs’ slate was lighter. Those two things allowed us to create seven open, staffed, ready ORs in a very short period of time.
"Within the ED, we deployed [emergency physicians] and surgeons and nurses into a number of trauma teams. At one point we had more than 10 teams, and they were all ready to receive patients, which turned out to be very important," Dr. Walls said.
At press time, none of more than 170 patients who were admitted to Boston area hospitals after the marathon had died, and physicians attribute this to great prehospital care, and lots of practice, preparation, and collaboration.
"It’s times like this that bring out the best in everybody," Dr. Wolfe said. "People are willing to help, they’re willing to collaborate. Egos dissipate and people tend to work together the way you just don’t see on a regular basis, which is absolutely lovely. From my standpoint, watching how well the teams worked, sort of was a validation of what emergency medicine is all about, and what emergency medicine training is."
"This was an amazing example for me, not that I really needed one, on how valuable every single person in the emergency department is," Dr. Walls said. "It’s the physicians and nurses, but it is also the aides, and the registration people and the housekeepers and everybody in the ED who have to do their jobs magnificently to make this work. And on that day, they all did."
On Twitter @NaseemSMiller
If there’s one piece of advice that Boston emergency physicians have for their peers following the Boston Marathon bombings, it’s this: drill, drill, drill.
"No matter how much drilling you do, you will never really prepare yourself for what this is like," said Dr. Ron M. Walls, chairman of the department of emergency medicine at Brigham and Women’s Hospital.
"But I would encourage everyone to plan those drills, take them seriously, do them well, and do them often. There’s no question that the expertise of emergency physicians and surgeons and nurses is crucial at the time of response, but being part of the systematic response and knowing that you’re part of systematic response is also very important."
On Monday afternoon, April 15, before the two improvised explosive devices detonated near the finish line of the Boston Marathon, killing three and injuring more than 170 people, Dr. Walls was in his office with his department administrator going over the budget. Suddenly, an alert went through the phone system. A news banner popped up on his phone.
"And then I heard an absolute cacophony of sirens, more than I had ever heard anywhere," he said in an interview.
Boston is unique when it comes to emergency and trauma care. It has five level 1 trauma centers. And Massachusetts was one of the first states to ban ambulance diversions in 2009. As a result, hospitals have created protocols to move patients quickly and make room in the ED.
"EMS [emergency medical services] did a beautiful job of distributing the patients at Beth Israel Deaconess Medical Center. There wasn’t any point where we felt truly overwhelmed," said Dr. Richard E. Wolfe, chief of emergency medicine at the medical center.
And the drills and preparations helped. While mass casualty drills have been a part of hospital operations for years, the 9/11 terrorist attacks brought the importance of preparation to the forefront.
"We’ve had a big shift in education," said Col. John McManus, MC, USA (ret.), an emergency physician who was among the last to leave Iraq in 2011. "Even though we learned a lot of these lessons from World War II and Vietnam, we kind of forgot about some of it. They were published, but we didn’t keep them in the cutting edge of medicine. We felt like it was never going to happen here, and that the military had to deal with it. After 9/11, unfortunately, we realized that we were underprepared and undertrained to treat these kinds of casualties."
Brigham and Women’s Hospital has held 73 disaster preparation drills since 2006, including citywide drills with Boston EMS, Dr. Walls said.
Now, the many hospitals have physicians, nurses, and other personnel on staff who have served in combat situations. Federal agencies, medical societies, and private entities are collaborating to update training and medical information. "The majority of scientific meetings include military and blast education," Dr. McManus, vice president of medical affairs at Masimo Corporation, said in an interview.
"What’s happened since Sept. 11 is that people are much more focused on disaster management and mass casualty events," Dr. Wolfe said in an interview. At Beth Israel Deaconess Medical Center, "we’ve had speakers from Israel doing visiting fellowships with us. We had Dr. Chris Caldwell, who helped coordinate the Aurora and Columbine disaster responses, as a visiting professor with us, walking us through the lessons learned in Columbine.
"It’s become part of residency training and didactic programs, and has really developed a culture of knowledge in terms of mass casualty events, in a way that we didn’t have in the 80s and 90s," Dr. Wolfe said.
And after each disaster, be it Hurricane Katrina or the Boston Marathon, hospitals improve their protocols and share what they’ve learned. Both Dr. Walls and Dr. Wolfe said they wanted to improve communication, whether it’s within the hospital and between the departments, or whether it’s with outside staff who may feel left out of the loop.
On Monday afternoon, Dr. Wolfe had just gotten home when he saw television reports of the bombing. He called his ED and headed back to work. Within minutes, ED personnel levels increased fivefold as patients began to arrive.
He quickly established crowd control in the ED, and put some of the volunteers on the reserve and on the sidelines. He also created zones, where people worked in small pockets. There was a disaster coordinator on the scene "so we had all the right people," Dr. Wolfe said.
Out front, social workers dealt with others who were arriving at the hospital. Registration was "very focused on getting real names so that we wouldn’t lose any patients to mistaken identity," he said. Patients were quickly assessed as they arrived, then flowed rapidly to the next stage of care, whether it was operating room or intensive care."
At Brigham and Women’s, the emergency department received a total of 35 patients, 28 of whom arrived in an hour.
"When this started, we had a pretty full ED," said Dr. Walls, professor of medicine at Harvard Medical School. "We decompressed by moving some of the patients out of the ED or into inpatient units. We created a lot of capacity in a short period of time. At the same time, we had alerted the OR, and it happened to be shift change, so we froze the staff, resulting in double staffing. And it was Monday afternoon on a holiday, so the ORs’ slate was lighter. Those two things allowed us to create seven open, staffed, ready ORs in a very short period of time.
"Within the ED, we deployed [emergency physicians] and surgeons and nurses into a number of trauma teams. At one point we had more than 10 teams, and they were all ready to receive patients, which turned out to be very important," Dr. Walls said.
At press time, none of more than 170 patients who were admitted to Boston area hospitals after the marathon had died, and physicians attribute this to great prehospital care, and lots of practice, preparation, and collaboration.
"It’s times like this that bring out the best in everybody," Dr. Wolfe said. "People are willing to help, they’re willing to collaborate. Egos dissipate and people tend to work together the way you just don’t see on a regular basis, which is absolutely lovely. From my standpoint, watching how well the teams worked, sort of was a validation of what emergency medicine is all about, and what emergency medicine training is."
"This was an amazing example for me, not that I really needed one, on how valuable every single person in the emergency department is," Dr. Walls said. "It’s the physicians and nurses, but it is also the aides, and the registration people and the housekeepers and everybody in the ED who have to do their jobs magnificently to make this work. And on that day, they all did."
On Twitter @NaseemSMiller
If there’s one piece of advice that Boston emergency physicians have for their peers following the Boston Marathon bombings, it’s this: drill, drill, drill.
"No matter how much drilling you do, you will never really prepare yourself for what this is like," said Dr. Ron M. Walls, chairman of the department of emergency medicine at Brigham and Women’s Hospital.
"But I would encourage everyone to plan those drills, take them seriously, do them well, and do them often. There’s no question that the expertise of emergency physicians and surgeons and nurses is crucial at the time of response, but being part of the systematic response and knowing that you’re part of systematic response is also very important."
On Monday afternoon, April 15, before the two improvised explosive devices detonated near the finish line of the Boston Marathon, killing three and injuring more than 170 people, Dr. Walls was in his office with his department administrator going over the budget. Suddenly, an alert went through the phone system. A news banner popped up on his phone.
"And then I heard an absolute cacophony of sirens, more than I had ever heard anywhere," he said in an interview.
Boston is unique when it comes to emergency and trauma care. It has five level 1 trauma centers. And Massachusetts was one of the first states to ban ambulance diversions in 2009. As a result, hospitals have created protocols to move patients quickly and make room in the ED.
"EMS [emergency medical services] did a beautiful job of distributing the patients at Beth Israel Deaconess Medical Center. There wasn’t any point where we felt truly overwhelmed," said Dr. Richard E. Wolfe, chief of emergency medicine at the medical center.
And the drills and preparations helped. While mass casualty drills have been a part of hospital operations for years, the 9/11 terrorist attacks brought the importance of preparation to the forefront.
"We’ve had a big shift in education," said Col. John McManus, MC, USA (ret.), an emergency physician who was among the last to leave Iraq in 2011. "Even though we learned a lot of these lessons from World War II and Vietnam, we kind of forgot about some of it. They were published, but we didn’t keep them in the cutting edge of medicine. We felt like it was never going to happen here, and that the military had to deal with it. After 9/11, unfortunately, we realized that we were underprepared and undertrained to treat these kinds of casualties."
Brigham and Women’s Hospital has held 73 disaster preparation drills since 2006, including citywide drills with Boston EMS, Dr. Walls said.
Now, the many hospitals have physicians, nurses, and other personnel on staff who have served in combat situations. Federal agencies, medical societies, and private entities are collaborating to update training and medical information. "The majority of scientific meetings include military and blast education," Dr. McManus, vice president of medical affairs at Masimo Corporation, said in an interview.
"What’s happened since Sept. 11 is that people are much more focused on disaster management and mass casualty events," Dr. Wolfe said in an interview. At Beth Israel Deaconess Medical Center, "we’ve had speakers from Israel doing visiting fellowships with us. We had Dr. Chris Caldwell, who helped coordinate the Aurora and Columbine disaster responses, as a visiting professor with us, walking us through the lessons learned in Columbine.
"It’s become part of residency training and didactic programs, and has really developed a culture of knowledge in terms of mass casualty events, in a way that we didn’t have in the 80s and 90s," Dr. Wolfe said.
And after each disaster, be it Hurricane Katrina or the Boston Marathon, hospitals improve their protocols and share what they’ve learned. Both Dr. Walls and Dr. Wolfe said they wanted to improve communication, whether it’s within the hospital and between the departments, or whether it’s with outside staff who may feel left out of the loop.
On Monday afternoon, Dr. Wolfe had just gotten home when he saw television reports of the bombing. He called his ED and headed back to work. Within minutes, ED personnel levels increased fivefold as patients began to arrive.
He quickly established crowd control in the ED, and put some of the volunteers on the reserve and on the sidelines. He also created zones, where people worked in small pockets. There was a disaster coordinator on the scene "so we had all the right people," Dr. Wolfe said.
Out front, social workers dealt with others who were arriving at the hospital. Registration was "very focused on getting real names so that we wouldn’t lose any patients to mistaken identity," he said. Patients were quickly assessed as they arrived, then flowed rapidly to the next stage of care, whether it was operating room or intensive care."
At Brigham and Women’s, the emergency department received a total of 35 patients, 28 of whom arrived in an hour.
"When this started, we had a pretty full ED," said Dr. Walls, professor of medicine at Harvard Medical School. "We decompressed by moving some of the patients out of the ED or into inpatient units. We created a lot of capacity in a short period of time. At the same time, we had alerted the OR, and it happened to be shift change, so we froze the staff, resulting in double staffing. And it was Monday afternoon on a holiday, so the ORs’ slate was lighter. Those two things allowed us to create seven open, staffed, ready ORs in a very short period of time.
"Within the ED, we deployed [emergency physicians] and surgeons and nurses into a number of trauma teams. At one point we had more than 10 teams, and they were all ready to receive patients, which turned out to be very important," Dr. Walls said.
At press time, none of more than 170 patients who were admitted to Boston area hospitals after the marathon had died, and physicians attribute this to great prehospital care, and lots of practice, preparation, and collaboration.
"It’s times like this that bring out the best in everybody," Dr. Wolfe said. "People are willing to help, they’re willing to collaborate. Egos dissipate and people tend to work together the way you just don’t see on a regular basis, which is absolutely lovely. From my standpoint, watching how well the teams worked, sort of was a validation of what emergency medicine is all about, and what emergency medicine training is."
"This was an amazing example for me, not that I really needed one, on how valuable every single person in the emergency department is," Dr. Walls said. "It’s the physicians and nurses, but it is also the aides, and the registration people and the housekeepers and everybody in the ED who have to do their jobs magnificently to make this work. And on that day, they all did."
On Twitter @NaseemSMiller
Storify: After Boston Marathon blasts, doctors rush to help
Axitinib eyed as first-line therapy for mRCC
ORLANDO – Compared with sorafenib, axitinib as first-line therapy was associated with a 3.6 month improvement in progression-free survival among patients with metastatic renal cell carcinoma.
The median PFS was 10.1 months in the axitinib arm and 6.5 months in the sorafenib arm. (hazard ratio, 0.77; one-sided P = .038). The results did not reach the predetermined significance level of 0.025, and hence the trial didn’t achieve its primary endpoint, said Dr. Thomas E. Hutson at the annual Gastrointestinal Cancers Symposium sponsored by the American Society of Clinical Oncology.
No differences in overall survival data have been noted to date in the ongoing phase III trial. Dr. Hutson of Texas Oncology – Baylor Charles A. Sammons Cancer Center, Dallas, and the study’s lead author, said that researchers are waiting for the survival data to mature.
Axitinib is a vascular endothelial growth factor receptor inhibitor that is approved for advanced renal cell carcinoma (RCC) after one prior systemic therapy has failed.
To examine the value of axitinib as a first-line therapy, researchers took into account results from previous clinical trials (J. Clin. Oncol. 2009; 27:1280-9) and amended an ongoing randomized trial of second-line axitinib vs. sorafenib to include a population of first-line therapy patients.
The Pfizer-sponsored multicenter, randomized, open-label, phase III trial included 288 untreated patients with clear-cell mRCC who had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Patients were randomized 2:1 to axitinib (5 mg, twice daily) or to sorafenib (400 mg, twice daily.) The randomization was stratified by ECOG performance status.
The primary endpoint was progression-free survival (PFS) as determined by an independent radiology committee. The study had a 90% power to detect a 78% improvement in PFS.
Secondary endpoints included overall survival, objective response rate, safety, duration of response, kidney cancer–specific symptoms, and health-related quality of life.
Patients’ baseline characteristics were well balanced between the two arms, and median patient age was 58 years old. ECOG performance status was 0 for 57% and 1 for 43%. Nephrectomies were performed in 85% of patients in the axitinib arm and 90% in the sorafenib arm. About 14% of the patients were from North America.
Patients who had a nephrectomy and an ECOG performance status of 0 faired better if they were in the axitinib arm. Among patients who had a nephrectomy, axitinib-treated patients had a median PFS of 10.3 months and sorafenib-treated patients had a median PFS of 6.4 months (HR, 0.67*; one-sided P = .009). Patients with an ECOG performance status of 0 had a median PFS of 13.7 months in the axitinib arm and 6.6 months in the sorafenib arm (HR, 0.644; one-sided P =.022). Patients with an ECOG performance status of 1 had similar median PFS – 6.5 months in the axitinib arm and 6.4 months in sorafenib arm.
Objective response rate was 32.3% with axitinib and 14.6% with sorafenib.
Patients in the axitinib arm had more hypertension and diarrhea (49% vs. 29% with sorafenib, and 50% vs. 40% with sorafenib.) Palmar-plantar erythrodysesthesia was more common with sorafenib (39% vs. 26% with axitinib).
Dr. Hutson has been a consultant or adviser for, and has received honoraria and research funding from AVEO, Bayer, GlaxoSmithKline, Novartis, and Pfizer, the maker of axitinib.
*Correction, 4/17/2013: An earlier version of this story misstated the HR value in patients who had nephrectomy.
ORLANDO – Compared with sorafenib, axitinib as first-line therapy was associated with a 3.6 month improvement in progression-free survival among patients with metastatic renal cell carcinoma.
The median PFS was 10.1 months in the axitinib arm and 6.5 months in the sorafenib arm. (hazard ratio, 0.77; one-sided P = .038). The results did not reach the predetermined significance level of 0.025, and hence the trial didn’t achieve its primary endpoint, said Dr. Thomas E. Hutson at the annual Gastrointestinal Cancers Symposium sponsored by the American Society of Clinical Oncology.
No differences in overall survival data have been noted to date in the ongoing phase III trial. Dr. Hutson of Texas Oncology – Baylor Charles A. Sammons Cancer Center, Dallas, and the study’s lead author, said that researchers are waiting for the survival data to mature.
Axitinib is a vascular endothelial growth factor receptor inhibitor that is approved for advanced renal cell carcinoma (RCC) after one prior systemic therapy has failed.
To examine the value of axitinib as a first-line therapy, researchers took into account results from previous clinical trials (J. Clin. Oncol. 2009; 27:1280-9) and amended an ongoing randomized trial of second-line axitinib vs. sorafenib to include a population of first-line therapy patients.
The Pfizer-sponsored multicenter, randomized, open-label, phase III trial included 288 untreated patients with clear-cell mRCC who had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Patients were randomized 2:1 to axitinib (5 mg, twice daily) or to sorafenib (400 mg, twice daily.) The randomization was stratified by ECOG performance status.
The primary endpoint was progression-free survival (PFS) as determined by an independent radiology committee. The study had a 90% power to detect a 78% improvement in PFS.
Secondary endpoints included overall survival, objective response rate, safety, duration of response, kidney cancer–specific symptoms, and health-related quality of life.
Patients’ baseline characteristics were well balanced between the two arms, and median patient age was 58 years old. ECOG performance status was 0 for 57% and 1 for 43%. Nephrectomies were performed in 85% of patients in the axitinib arm and 90% in the sorafenib arm. About 14% of the patients were from North America.
Patients who had a nephrectomy and an ECOG performance status of 0 faired better if they were in the axitinib arm. Among patients who had a nephrectomy, axitinib-treated patients had a median PFS of 10.3 months and sorafenib-treated patients had a median PFS of 6.4 months (HR, 0.67*; one-sided P = .009). Patients with an ECOG performance status of 0 had a median PFS of 13.7 months in the axitinib arm and 6.6 months in the sorafenib arm (HR, 0.644; one-sided P =.022). Patients with an ECOG performance status of 1 had similar median PFS – 6.5 months in the axitinib arm and 6.4 months in sorafenib arm.
Objective response rate was 32.3% with axitinib and 14.6% with sorafenib.
Patients in the axitinib arm had more hypertension and diarrhea (49% vs. 29% with sorafenib, and 50% vs. 40% with sorafenib.) Palmar-plantar erythrodysesthesia was more common with sorafenib (39% vs. 26% with axitinib).
Dr. Hutson has been a consultant or adviser for, and has received honoraria and research funding from AVEO, Bayer, GlaxoSmithKline, Novartis, and Pfizer, the maker of axitinib.
*Correction, 4/17/2013: An earlier version of this story misstated the HR value in patients who had nephrectomy.
ORLANDO – Compared with sorafenib, axitinib as first-line therapy was associated with a 3.6 month improvement in progression-free survival among patients with metastatic renal cell carcinoma.
The median PFS was 10.1 months in the axitinib arm and 6.5 months in the sorafenib arm. (hazard ratio, 0.77; one-sided P = .038). The results did not reach the predetermined significance level of 0.025, and hence the trial didn’t achieve its primary endpoint, said Dr. Thomas E. Hutson at the annual Gastrointestinal Cancers Symposium sponsored by the American Society of Clinical Oncology.
No differences in overall survival data have been noted to date in the ongoing phase III trial. Dr. Hutson of Texas Oncology – Baylor Charles A. Sammons Cancer Center, Dallas, and the study’s lead author, said that researchers are waiting for the survival data to mature.
Axitinib is a vascular endothelial growth factor receptor inhibitor that is approved for advanced renal cell carcinoma (RCC) after one prior systemic therapy has failed.
To examine the value of axitinib as a first-line therapy, researchers took into account results from previous clinical trials (J. Clin. Oncol. 2009; 27:1280-9) and amended an ongoing randomized trial of second-line axitinib vs. sorafenib to include a population of first-line therapy patients.
The Pfizer-sponsored multicenter, randomized, open-label, phase III trial included 288 untreated patients with clear-cell mRCC who had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Patients were randomized 2:1 to axitinib (5 mg, twice daily) or to sorafenib (400 mg, twice daily.) The randomization was stratified by ECOG performance status.
The primary endpoint was progression-free survival (PFS) as determined by an independent radiology committee. The study had a 90% power to detect a 78% improvement in PFS.
Secondary endpoints included overall survival, objective response rate, safety, duration of response, kidney cancer–specific symptoms, and health-related quality of life.
Patients’ baseline characteristics were well balanced between the two arms, and median patient age was 58 years old. ECOG performance status was 0 for 57% and 1 for 43%. Nephrectomies were performed in 85% of patients in the axitinib arm and 90% in the sorafenib arm. About 14% of the patients were from North America.
Patients who had a nephrectomy and an ECOG performance status of 0 faired better if they were in the axitinib arm. Among patients who had a nephrectomy, axitinib-treated patients had a median PFS of 10.3 months and sorafenib-treated patients had a median PFS of 6.4 months (HR, 0.67*; one-sided P = .009). Patients with an ECOG performance status of 0 had a median PFS of 13.7 months in the axitinib arm and 6.6 months in the sorafenib arm (HR, 0.644; one-sided P =.022). Patients with an ECOG performance status of 1 had similar median PFS – 6.5 months in the axitinib arm and 6.4 months in sorafenib arm.
Objective response rate was 32.3% with axitinib and 14.6% with sorafenib.
Patients in the axitinib arm had more hypertension and diarrhea (49% vs. 29% with sorafenib, and 50% vs. 40% with sorafenib.) Palmar-plantar erythrodysesthesia was more common with sorafenib (39% vs. 26% with axitinib).
Dr. Hutson has been a consultant or adviser for, and has received honoraria and research funding from AVEO, Bayer, GlaxoSmithKline, Novartis, and Pfizer, the maker of axitinib.
*Correction, 4/17/2013: An earlier version of this story misstated the HR value in patients who had nephrectomy.
AT THE ASCO GENITOURINARY CANCERS SYMPOSIUM
Major finding: Median progression-free survival was 10.1 months in the axitinib arm and 6.5 months in the sorafenib arm. (HR, 0.77; one-sided P = .038).
Data source: A multicenter, randomized, open-label trial of 288 untreated patients with clear-cell mRCC.
Disclosures: Dr. Hutson has been a consultant or advisor for, and has received honoraria and research funding from several drug makers including Pfizer, the maker of axitinib.
Fetal thigh measurement may predict adiposity
ORLANDO – Fetal thigh measurement at 28 weeks can help identify babies who are at risk of neonatal adiposity, according to a small exploratory study.
The study also showed that abdominal circumference and estimated fetal weight at 28 weeks’ gestation were not correlated with adiposity at birth, nor were prepregnancy body mass index, maternal weight gain, or birth weight.
With a nation facing an obesity epidemic, the study may provide yet another tool to combat the trend by opening the possibility of fetal-based interventions, hence reducing the risk of childhood obesity.
Compared with birth weight, adiposity at birth has been known to be a stronger predictor of childhood obesity, said Dr. Gaea S. Moore of the University of Colorado, Aurora, who presented the abstract at the annual meetingof the Society of Gynecologic Investigation.
But, there’s not yet a good way of measuring how much fat the baby is going to have, said Dr. Anna L. David of University College London Elizabeth Garrett Anderson Institute for Women’s Health, London, who moderated the session. "So this study looks very promising," she said.
While 2D fetal ultrasound has not been a strong tool in measuring fetal adiposity, adding 3D fractional limb volumes (FLV) has helped improve the prediction of both adiposity at birth and macrosomia.
Dr. Moore and her colleagues conducted a prospective cohort study of 18 pregnant women, collecting data from standard 2D ultrasound biometry and mid-thigh cross sectional areas (MTA), and 3D FLV, measuring thigh volume at the 50% of the femur, using a 5-slice technique. Both measurements were analyzed with the 4D View software.
Seven of the 18 subjects were excluded due to poor image quality.
The mean age of mothers was 30 years, with prepregnancy body mass index of 26, parity of 0.83, and the mean gestational age at birth of 39 weeks and 3 days.
Researchers measured neonatal body composition with air displacement plethysmography (Pea Pod) 14 days after birth. The mean birth weight of the infants was 3,383 g, and the mean body fat was 10.68%.
Analyses showed that fetal thigh measurement at 28 weeks correlated with neonatal adiposity. FLV and MTA correlated with adiposity at 28 weeks when normalized for femur length (FL). (FLV/FL, r = 0.77; P = .005. MTA/FL, r = 0.75; P = .007)
The correlation further improved with adjustment of thigh volumes by femur length, and by adjustment for Pea Pod timing and gestational age adjustments.
The study opens the possibility of obtaining data that could lead to a conversation with pregnant moms whose babies might be at risk of neonatal adiposity, Dr. David said. "Maybe there’s an intervention that could reduce the adiposity," she said, whether it’s giving the mother medications that would reduce the sugar going across the placenta, or manipulation of diet.
She also pointed out that larger studies were needed, and that 28 weeks may not be the optimum time for measurement, as seven subjects were excluded due to poor image quality. "At 20 weeks there’s relatively more fluid around the baby, so maybe that might be a better time to take the measurement." She said that the measurement’s accuracy is yet to be determined.
Dr. Moore and her colleagues have obtained measurements at 36 weeks, but have not analyzed the data. She said the group had not evaluated data for earlier than 20 weeks’ gestation.
Dr. Moore and Dr. David reported no disclosures.
On Twitter @naseemsmiller
ORLANDO – Fetal thigh measurement at 28 weeks can help identify babies who are at risk of neonatal adiposity, according to a small exploratory study.
The study also showed that abdominal circumference and estimated fetal weight at 28 weeks’ gestation were not correlated with adiposity at birth, nor were prepregnancy body mass index, maternal weight gain, or birth weight.
With a nation facing an obesity epidemic, the study may provide yet another tool to combat the trend by opening the possibility of fetal-based interventions, hence reducing the risk of childhood obesity.
Compared with birth weight, adiposity at birth has been known to be a stronger predictor of childhood obesity, said Dr. Gaea S. Moore of the University of Colorado, Aurora, who presented the abstract at the annual meetingof the Society of Gynecologic Investigation.
But, there’s not yet a good way of measuring how much fat the baby is going to have, said Dr. Anna L. David of University College London Elizabeth Garrett Anderson Institute for Women’s Health, London, who moderated the session. "So this study looks very promising," she said.
While 2D fetal ultrasound has not been a strong tool in measuring fetal adiposity, adding 3D fractional limb volumes (FLV) has helped improve the prediction of both adiposity at birth and macrosomia.
Dr. Moore and her colleagues conducted a prospective cohort study of 18 pregnant women, collecting data from standard 2D ultrasound biometry and mid-thigh cross sectional areas (MTA), and 3D FLV, measuring thigh volume at the 50% of the femur, using a 5-slice technique. Both measurements were analyzed with the 4D View software.
Seven of the 18 subjects were excluded due to poor image quality.
The mean age of mothers was 30 years, with prepregnancy body mass index of 26, parity of 0.83, and the mean gestational age at birth of 39 weeks and 3 days.
Researchers measured neonatal body composition with air displacement plethysmography (Pea Pod) 14 days after birth. The mean birth weight of the infants was 3,383 g, and the mean body fat was 10.68%.
Analyses showed that fetal thigh measurement at 28 weeks correlated with neonatal adiposity. FLV and MTA correlated with adiposity at 28 weeks when normalized for femur length (FL). (FLV/FL, r = 0.77; P = .005. MTA/FL, r = 0.75; P = .007)
The correlation further improved with adjustment of thigh volumes by femur length, and by adjustment for Pea Pod timing and gestational age adjustments.
The study opens the possibility of obtaining data that could lead to a conversation with pregnant moms whose babies might be at risk of neonatal adiposity, Dr. David said. "Maybe there’s an intervention that could reduce the adiposity," she said, whether it’s giving the mother medications that would reduce the sugar going across the placenta, or manipulation of diet.
She also pointed out that larger studies were needed, and that 28 weeks may not be the optimum time for measurement, as seven subjects were excluded due to poor image quality. "At 20 weeks there’s relatively more fluid around the baby, so maybe that might be a better time to take the measurement." She said that the measurement’s accuracy is yet to be determined.
Dr. Moore and her colleagues have obtained measurements at 36 weeks, but have not analyzed the data. She said the group had not evaluated data for earlier than 20 weeks’ gestation.
Dr. Moore and Dr. David reported no disclosures.
On Twitter @naseemsmiller
ORLANDO – Fetal thigh measurement at 28 weeks can help identify babies who are at risk of neonatal adiposity, according to a small exploratory study.
The study also showed that abdominal circumference and estimated fetal weight at 28 weeks’ gestation were not correlated with adiposity at birth, nor were prepregnancy body mass index, maternal weight gain, or birth weight.
With a nation facing an obesity epidemic, the study may provide yet another tool to combat the trend by opening the possibility of fetal-based interventions, hence reducing the risk of childhood obesity.
Compared with birth weight, adiposity at birth has been known to be a stronger predictor of childhood obesity, said Dr. Gaea S. Moore of the University of Colorado, Aurora, who presented the abstract at the annual meetingof the Society of Gynecologic Investigation.
But, there’s not yet a good way of measuring how much fat the baby is going to have, said Dr. Anna L. David of University College London Elizabeth Garrett Anderson Institute for Women’s Health, London, who moderated the session. "So this study looks very promising," she said.
While 2D fetal ultrasound has not been a strong tool in measuring fetal adiposity, adding 3D fractional limb volumes (FLV) has helped improve the prediction of both adiposity at birth and macrosomia.
Dr. Moore and her colleagues conducted a prospective cohort study of 18 pregnant women, collecting data from standard 2D ultrasound biometry and mid-thigh cross sectional areas (MTA), and 3D FLV, measuring thigh volume at the 50% of the femur, using a 5-slice technique. Both measurements were analyzed with the 4D View software.
Seven of the 18 subjects were excluded due to poor image quality.
The mean age of mothers was 30 years, with prepregnancy body mass index of 26, parity of 0.83, and the mean gestational age at birth of 39 weeks and 3 days.
Researchers measured neonatal body composition with air displacement plethysmography (Pea Pod) 14 days after birth. The mean birth weight of the infants was 3,383 g, and the mean body fat was 10.68%.
Analyses showed that fetal thigh measurement at 28 weeks correlated with neonatal adiposity. FLV and MTA correlated with adiposity at 28 weeks when normalized for femur length (FL). (FLV/FL, r = 0.77; P = .005. MTA/FL, r = 0.75; P = .007)
The correlation further improved with adjustment of thigh volumes by femur length, and by adjustment for Pea Pod timing and gestational age adjustments.
The study opens the possibility of obtaining data that could lead to a conversation with pregnant moms whose babies might be at risk of neonatal adiposity, Dr. David said. "Maybe there’s an intervention that could reduce the adiposity," she said, whether it’s giving the mother medications that would reduce the sugar going across the placenta, or manipulation of diet.
She also pointed out that larger studies were needed, and that 28 weeks may not be the optimum time for measurement, as seven subjects were excluded due to poor image quality. "At 20 weeks there’s relatively more fluid around the baby, so maybe that might be a better time to take the measurement." She said that the measurement’s accuracy is yet to be determined.
Dr. Moore and her colleagues have obtained measurements at 36 weeks, but have not analyzed the data. She said the group had not evaluated data for earlier than 20 weeks’ gestation.
Dr. Moore and Dr. David reported no disclosures.
On Twitter @naseemsmiller
AT THE ANNUAL MEETING OF THE SOCIETY OF GYNECOLOGIC INVESTIGATION
Major Finding: Fetal thigh measurement at 28 weeks correlated with neonatal adiposity. (FLV/FL, r = 0.77; P = .005. MTA/FL, r = 0.75; P = .007).
Data Source: A prospective cohort study of 18 pregnant women, with data from standard 2D ultrasound biometry and mid-thigh cross-sectional areas, and 3D FLV, measuring thigh volume at the 50% of the femur, with a 5-slice technique.
Disclosures: Dr. Moore and Dr. David reported no disclosures.
Laser choice enhances hair removal for darker skin
MIAMI BEACH – Choosing the right laser and the correct parameters, along with proper patient selection and counseling, can reduce the risk of complications and promote safe and effective hair removal in skin of color patients, according to Dr. H. Ray Jalian of the University of California, Los Angeles.
Patient selection and counseling come first, Dr. Jalian said at the annual meeting of the American Academy of Dermatology. Explain to darker-skinned patients that they may need more treatments than patients with lighter skin (Fitzpatrick types I to III), he said.
Both the 800-810-nm long-pulsed diode laser and the long-pulsed 1064 Nd:YAG laser have proven safe and effective in laser hair removal in darker skin types, but Dr. Jalian said he prefers the long-pulsed 1064 Nd:YAG.
To improve safety, pay attention to the laser parameters, Dr. Jalian advised. Use longer wavelengths to ensure less melanin absorption, he said. In addition, the pulse duration should to be longer than the thermal relaxation time (TRT) of the epidermal melanosomes. For example, the TRT for a melanosome is 250 ns, and a typical laser pulse duration is 10-100 ns; the TRT for a terminal hair follicle is 100 ms, and a typical pulse duration is 3-100 ms, he said.
Before a procedure, Dr. Jalian advises his patients to use sun protection and to shave the area, because the burning hair can act like a "hot coal." He also puts patients on oral antibiotics if they report a history of pseudofolliculitis barbae flares.
In addition, "perform the procedure on a test spot that’s representative of the area for hair removal, and reevaluate it in 4 weeks before treating the entire area," said Dr. Jalian.
During the procedure, look for desired endpoints, including perifollicular erythema and singed hairs. But also look for undesired endpoints, including epidermal graying, blisters, and excessive pain, Dr. Jalian said.
He also recommended epidermal cooling to minimize epidermal damage caused by the absorption of light by melanin. Cooling strategies include using passive cooling methods such as cold gel, and using the cooling tools available on many lasers, such as the sapphire tip, cryogen spray, and forced chilled air, he added.
"And remember that there can be too much of a good thing," in terms of cooling, said Dr. Jalian. "There should be a balance between heating and cooling of the skin to achieve best results."
After a laser hair removal procedure, he recommends a single application of a midpotency topical steroid, and sun protection.
Common complications of laser hair removal in darker skin types include hyperpigmentation and hypopigmentation, infections and folliculitis, scarring, and eye injury. Dr. Jalian advised against using an Nd:YAG laser close to the orbit of the eye to reduce the odds of such an injury.
Paradoxical hypertrichosis after laser hair removal has been reported, mostly in darker skin types, and with all light sources. Some risk factors include Mediterranean, Middle Eastern, and Indian ethnicities, a low-set frontal hair line, and fine or intermediate hair. Subtherapeutic fluence also may cause induction of hair cycle at the edge of a laser spot, he said.
Dr. Jalian had no financial conflicts to disclose.
On Twitter @naseemsmiller
MIAMI BEACH – Choosing the right laser and the correct parameters, along with proper patient selection and counseling, can reduce the risk of complications and promote safe and effective hair removal in skin of color patients, according to Dr. H. Ray Jalian of the University of California, Los Angeles.
Patient selection and counseling come first, Dr. Jalian said at the annual meeting of the American Academy of Dermatology. Explain to darker-skinned patients that they may need more treatments than patients with lighter skin (Fitzpatrick types I to III), he said.
Both the 800-810-nm long-pulsed diode laser and the long-pulsed 1064 Nd:YAG laser have proven safe and effective in laser hair removal in darker skin types, but Dr. Jalian said he prefers the long-pulsed 1064 Nd:YAG.
To improve safety, pay attention to the laser parameters, Dr. Jalian advised. Use longer wavelengths to ensure less melanin absorption, he said. In addition, the pulse duration should to be longer than the thermal relaxation time (TRT) of the epidermal melanosomes. For example, the TRT for a melanosome is 250 ns, and a typical laser pulse duration is 10-100 ns; the TRT for a terminal hair follicle is 100 ms, and a typical pulse duration is 3-100 ms, he said.
Before a procedure, Dr. Jalian advises his patients to use sun protection and to shave the area, because the burning hair can act like a "hot coal." He also puts patients on oral antibiotics if they report a history of pseudofolliculitis barbae flares.
In addition, "perform the procedure on a test spot that’s representative of the area for hair removal, and reevaluate it in 4 weeks before treating the entire area," said Dr. Jalian.
During the procedure, look for desired endpoints, including perifollicular erythema and singed hairs. But also look for undesired endpoints, including epidermal graying, blisters, and excessive pain, Dr. Jalian said.
He also recommended epidermal cooling to minimize epidermal damage caused by the absorption of light by melanin. Cooling strategies include using passive cooling methods such as cold gel, and using the cooling tools available on many lasers, such as the sapphire tip, cryogen spray, and forced chilled air, he added.
"And remember that there can be too much of a good thing," in terms of cooling, said Dr. Jalian. "There should be a balance between heating and cooling of the skin to achieve best results."
After a laser hair removal procedure, he recommends a single application of a midpotency topical steroid, and sun protection.
Common complications of laser hair removal in darker skin types include hyperpigmentation and hypopigmentation, infections and folliculitis, scarring, and eye injury. Dr. Jalian advised against using an Nd:YAG laser close to the orbit of the eye to reduce the odds of such an injury.
Paradoxical hypertrichosis after laser hair removal has been reported, mostly in darker skin types, and with all light sources. Some risk factors include Mediterranean, Middle Eastern, and Indian ethnicities, a low-set frontal hair line, and fine or intermediate hair. Subtherapeutic fluence also may cause induction of hair cycle at the edge of a laser spot, he said.
Dr. Jalian had no financial conflicts to disclose.
On Twitter @naseemsmiller
MIAMI BEACH – Choosing the right laser and the correct parameters, along with proper patient selection and counseling, can reduce the risk of complications and promote safe and effective hair removal in skin of color patients, according to Dr. H. Ray Jalian of the University of California, Los Angeles.
Patient selection and counseling come first, Dr. Jalian said at the annual meeting of the American Academy of Dermatology. Explain to darker-skinned patients that they may need more treatments than patients with lighter skin (Fitzpatrick types I to III), he said.
Both the 800-810-nm long-pulsed diode laser and the long-pulsed 1064 Nd:YAG laser have proven safe and effective in laser hair removal in darker skin types, but Dr. Jalian said he prefers the long-pulsed 1064 Nd:YAG.
To improve safety, pay attention to the laser parameters, Dr. Jalian advised. Use longer wavelengths to ensure less melanin absorption, he said. In addition, the pulse duration should to be longer than the thermal relaxation time (TRT) of the epidermal melanosomes. For example, the TRT for a melanosome is 250 ns, and a typical laser pulse duration is 10-100 ns; the TRT for a terminal hair follicle is 100 ms, and a typical pulse duration is 3-100 ms, he said.
Before a procedure, Dr. Jalian advises his patients to use sun protection and to shave the area, because the burning hair can act like a "hot coal." He also puts patients on oral antibiotics if they report a history of pseudofolliculitis barbae flares.
In addition, "perform the procedure on a test spot that’s representative of the area for hair removal, and reevaluate it in 4 weeks before treating the entire area," said Dr. Jalian.
During the procedure, look for desired endpoints, including perifollicular erythema and singed hairs. But also look for undesired endpoints, including epidermal graying, blisters, and excessive pain, Dr. Jalian said.
He also recommended epidermal cooling to minimize epidermal damage caused by the absorption of light by melanin. Cooling strategies include using passive cooling methods such as cold gel, and using the cooling tools available on many lasers, such as the sapphire tip, cryogen spray, and forced chilled air, he added.
"And remember that there can be too much of a good thing," in terms of cooling, said Dr. Jalian. "There should be a balance between heating and cooling of the skin to achieve best results."
After a laser hair removal procedure, he recommends a single application of a midpotency topical steroid, and sun protection.
Common complications of laser hair removal in darker skin types include hyperpigmentation and hypopigmentation, infections and folliculitis, scarring, and eye injury. Dr. Jalian advised against using an Nd:YAG laser close to the orbit of the eye to reduce the odds of such an injury.
Paradoxical hypertrichosis after laser hair removal has been reported, mostly in darker skin types, and with all light sources. Some risk factors include Mediterranean, Middle Eastern, and Indian ethnicities, a low-set frontal hair line, and fine or intermediate hair. Subtherapeutic fluence also may cause induction of hair cycle at the edge of a laser spot, he said.
Dr. Jalian had no financial conflicts to disclose.
On Twitter @naseemsmiller
EXPERT ANALYSIS FROM THE AAD ANNUAL MEETING
AHA: Fewer than 1% of U.S. youth has ideal diet score
A snapshot of cardiovascular health in today’s youth bears no good news for their adult years or the future of the country’s public health, unless there are immediate and sweeping social and cultural changes, according to the American Heart Association.
The AHA’s examination of a sample representing more than 33 million U.S. adolescents showed that less than 1% had an ideal diet score. Less than half of adolescents achieved an ideal score in five or more of the seven cardiovascular health components measured in the study. None had ideal levels in all seven categories.
“The bad news is that an alarming proportion of US children between 12-19 years currently have poor levels of dietary intake and less than optimal levels of physical activity to maintain cardiovascular health,” said study’s lead author Christina M. Shay, Ph.D., University of Oklahoma Health Sciences Center, Oklahoma City. “These unfavorable lifestyle habits have likely already led to the high proportion of children in this study to also exhibit elevated levels of cholesterol, blood glucose, and blood pressure.” (Circulation 2013 April 2 [doi: 10.1161/CIRCULATIONAHA.113.001559]).
The good news, she said, “is that most of these unfavorable cardiovascular disease risk factors are modifiable through implementation of lifestyle change.”
The study follows a 2012 analysis of cardiovascular health in U.S. adults (Circulation 2012;125:45-56).
The AHA recently released the 2020 Strategic Impact Goals to help prevent cardiovascular disease and maintain cardiovascular health from youth throughout adulthood (Circulation 2010;121:586-613). The two analyses provide a baseline to measure progress toward that goal.
AHA defines cardiovascular health by seven health behaviors and factors: no smoking, body mass index, dietary intake, physical activity, blood pressure, blood glucose, and total cholesterol. It quantifies each category with a composite score for CV health with 0 for poor, 1 for intermediate, and 2 for ideal.
The authors examined components of cardiovascular health in 4,673 participants between ages 12 and 19 years from the 2005 to 2010 National Health and Nutrition Examination Surveys (NHANES). The sample group provides an estimated representation of 33.2 million U.S. adolescents.
The sample was well-balanced by sex. The majority of participants were non-Hispanic white (60%), and more than half reported an annual household income of $45,000 or more.
The examination of the data showed that fewer than half of adolescents exhibited five or more of AHA’s ideal cardiovascular health components (45% males and 50% females). Of the maximum score of 14, non-Hispanic white males and females had the highest median Cardiovascular Health Score (9.3 and 9.4 respectively). Mexican American meals and non-Hispanic black females had the lowest score (8.4 and 8.7 respectively).
Females, especially non-Hispanic whites, had a lower prevalence of ideal total cholesterol (65% females v. 72% males), and ideal physical activity (44% v. 67%).
Nearly two-third of the adolescents had an ideal body mass index (66% males and 67% females), but non-Hispanic black females and Mexican American males were more overweight or obese compared with non-Hispanic whites.
Also, nearly two-thirds had ideal smoking status (67% males and 70% females). Ideal smoking status was the most prevalent CV health behavior in all sex and race/ethnicity groups, especially among non-Hispanic blacks.
Ideal blood pressure was the most favorable cardiovascular health factor (78% males and 90% females.)
Meanwhile, females had a higher prevalence of ideal blood glucose (89% v. 74% males). Non-Hispanic blacks had the highest prevalence of ideal fasting blood glucose compared with non-Hispanic whites and Mexican Americans. Roughly a quarter of all adolescents had intermediate fasting blood glucose levels.
“Most children are born in a state of ideal cardiovascular health,” Dr. Shay said in an interview. “However, the poor lifestyles many U.S. children exhibit are leading to a loss of this important asset earlier and earlier in life. A stronger focus on emphasizing improvements in adolescent lifestyles needs to be implemented in the clinical setting.”
She added that “significant environmental and cultural changes need to be implemented with the assistance of parents, educators, health professionals, and legislators to promote healthier lifestyles of adolescents (and people of all ages) in order to improve the cardiovascular health of the US adolescent population.”Dr. Shay said her research team is currently comparing the cardiovascular health of the study’s population from 10 years ago to what it is today. “Considering the direction things have been going from then to now, we are estimating what things are going to look like in the year 2020.”
Her team is also working on estimating costs.
The study has several limitations, according to the authors. Although the data are nationally representative, they are cross-sectional and don’t represent temporal changes at an individual level. The data are also insufficient to obtain a confident diagnosis of clinical disease and as a result may underestimate ideal levels of CV health components. Also, the Cardiovascular Health Score does not weight the influence of each individual component, "and should be interpreted in light of this limitation," the authors noted.
They also noted that it is important to consider the fluctuations in health factors – such as increases in total cholesterol levels – that occur naturally during puberty and adolescence. Since NHANES is a cross-section, it does not allow for serial evaluation of CV factors, which could as a result increase the likelihood of misclassification.
The study was supported in part by a grant from the National Heart, Lung, and Blood Institute. None of the authors reported any disclosures except for Dr. Stephen R. Daniels who was the chair of the Data Safety and Monitoring Board for Merck Pharmaceuticals.
On Twitter @naseemsmiller
A snapshot of cardiovascular health in today’s youth bears no good news for their adult years or the future of the country’s public health, unless there are immediate and sweeping social and cultural changes, according to the American Heart Association.
The AHA’s examination of a sample representing more than 33 million U.S. adolescents showed that less than 1% had an ideal diet score. Less than half of adolescents achieved an ideal score in five or more of the seven cardiovascular health components measured in the study. None had ideal levels in all seven categories.
“The bad news is that an alarming proportion of US children between 12-19 years currently have poor levels of dietary intake and less than optimal levels of physical activity to maintain cardiovascular health,” said study’s lead author Christina M. Shay, Ph.D., University of Oklahoma Health Sciences Center, Oklahoma City. “These unfavorable lifestyle habits have likely already led to the high proportion of children in this study to also exhibit elevated levels of cholesterol, blood glucose, and blood pressure.” (Circulation 2013 April 2 [doi: 10.1161/CIRCULATIONAHA.113.001559]).
The good news, she said, “is that most of these unfavorable cardiovascular disease risk factors are modifiable through implementation of lifestyle change.”
The study follows a 2012 analysis of cardiovascular health in U.S. adults (Circulation 2012;125:45-56).
The AHA recently released the 2020 Strategic Impact Goals to help prevent cardiovascular disease and maintain cardiovascular health from youth throughout adulthood (Circulation 2010;121:586-613). The two analyses provide a baseline to measure progress toward that goal.
AHA defines cardiovascular health by seven health behaviors and factors: no smoking, body mass index, dietary intake, physical activity, blood pressure, blood glucose, and total cholesterol. It quantifies each category with a composite score for CV health with 0 for poor, 1 for intermediate, and 2 for ideal.
The authors examined components of cardiovascular health in 4,673 participants between ages 12 and 19 years from the 2005 to 2010 National Health and Nutrition Examination Surveys (NHANES). The sample group provides an estimated representation of 33.2 million U.S. adolescents.
The sample was well-balanced by sex. The majority of participants were non-Hispanic white (60%), and more than half reported an annual household income of $45,000 or more.
The examination of the data showed that fewer than half of adolescents exhibited five or more of AHA’s ideal cardiovascular health components (45% males and 50% females). Of the maximum score of 14, non-Hispanic white males and females had the highest median Cardiovascular Health Score (9.3 and 9.4 respectively). Mexican American meals and non-Hispanic black females had the lowest score (8.4 and 8.7 respectively).
Females, especially non-Hispanic whites, had a lower prevalence of ideal total cholesterol (65% females v. 72% males), and ideal physical activity (44% v. 67%).
Nearly two-third of the adolescents had an ideal body mass index (66% males and 67% females), but non-Hispanic black females and Mexican American males were more overweight or obese compared with non-Hispanic whites.
Also, nearly two-thirds had ideal smoking status (67% males and 70% females). Ideal smoking status was the most prevalent CV health behavior in all sex and race/ethnicity groups, especially among non-Hispanic blacks.
Ideal blood pressure was the most favorable cardiovascular health factor (78% males and 90% females.)
Meanwhile, females had a higher prevalence of ideal blood glucose (89% v. 74% males). Non-Hispanic blacks had the highest prevalence of ideal fasting blood glucose compared with non-Hispanic whites and Mexican Americans. Roughly a quarter of all adolescents had intermediate fasting blood glucose levels.
“Most children are born in a state of ideal cardiovascular health,” Dr. Shay said in an interview. “However, the poor lifestyles many U.S. children exhibit are leading to a loss of this important asset earlier and earlier in life. A stronger focus on emphasizing improvements in adolescent lifestyles needs to be implemented in the clinical setting.”
She added that “significant environmental and cultural changes need to be implemented with the assistance of parents, educators, health professionals, and legislators to promote healthier lifestyles of adolescents (and people of all ages) in order to improve the cardiovascular health of the US adolescent population.”Dr. Shay said her research team is currently comparing the cardiovascular health of the study’s population from 10 years ago to what it is today. “Considering the direction things have been going from then to now, we are estimating what things are going to look like in the year 2020.”
Her team is also working on estimating costs.
The study has several limitations, according to the authors. Although the data are nationally representative, they are cross-sectional and don’t represent temporal changes at an individual level. The data are also insufficient to obtain a confident diagnosis of clinical disease and as a result may underestimate ideal levels of CV health components. Also, the Cardiovascular Health Score does not weight the influence of each individual component, "and should be interpreted in light of this limitation," the authors noted.
They also noted that it is important to consider the fluctuations in health factors – such as increases in total cholesterol levels – that occur naturally during puberty and adolescence. Since NHANES is a cross-section, it does not allow for serial evaluation of CV factors, which could as a result increase the likelihood of misclassification.
The study was supported in part by a grant from the National Heart, Lung, and Blood Institute. None of the authors reported any disclosures except for Dr. Stephen R. Daniels who was the chair of the Data Safety and Monitoring Board for Merck Pharmaceuticals.
On Twitter @naseemsmiller
A snapshot of cardiovascular health in today’s youth bears no good news for their adult years or the future of the country’s public health, unless there are immediate and sweeping social and cultural changes, according to the American Heart Association.
The AHA’s examination of a sample representing more than 33 million U.S. adolescents showed that less than 1% had an ideal diet score. Less than half of adolescents achieved an ideal score in five or more of the seven cardiovascular health components measured in the study. None had ideal levels in all seven categories.
“The bad news is that an alarming proportion of US children between 12-19 years currently have poor levels of dietary intake and less than optimal levels of physical activity to maintain cardiovascular health,” said study’s lead author Christina M. Shay, Ph.D., University of Oklahoma Health Sciences Center, Oklahoma City. “These unfavorable lifestyle habits have likely already led to the high proportion of children in this study to also exhibit elevated levels of cholesterol, blood glucose, and blood pressure.” (Circulation 2013 April 2 [doi: 10.1161/CIRCULATIONAHA.113.001559]).
The good news, she said, “is that most of these unfavorable cardiovascular disease risk factors are modifiable through implementation of lifestyle change.”
The study follows a 2012 analysis of cardiovascular health in U.S. adults (Circulation 2012;125:45-56).
The AHA recently released the 2020 Strategic Impact Goals to help prevent cardiovascular disease and maintain cardiovascular health from youth throughout adulthood (Circulation 2010;121:586-613). The two analyses provide a baseline to measure progress toward that goal.
AHA defines cardiovascular health by seven health behaviors and factors: no smoking, body mass index, dietary intake, physical activity, blood pressure, blood glucose, and total cholesterol. It quantifies each category with a composite score for CV health with 0 for poor, 1 for intermediate, and 2 for ideal.
The authors examined components of cardiovascular health in 4,673 participants between ages 12 and 19 years from the 2005 to 2010 National Health and Nutrition Examination Surveys (NHANES). The sample group provides an estimated representation of 33.2 million U.S. adolescents.
The sample was well-balanced by sex. The majority of participants were non-Hispanic white (60%), and more than half reported an annual household income of $45,000 or more.
The examination of the data showed that fewer than half of adolescents exhibited five or more of AHA’s ideal cardiovascular health components (45% males and 50% females). Of the maximum score of 14, non-Hispanic white males and females had the highest median Cardiovascular Health Score (9.3 and 9.4 respectively). Mexican American meals and non-Hispanic black females had the lowest score (8.4 and 8.7 respectively).
Females, especially non-Hispanic whites, had a lower prevalence of ideal total cholesterol (65% females v. 72% males), and ideal physical activity (44% v. 67%).
Nearly two-third of the adolescents had an ideal body mass index (66% males and 67% females), but non-Hispanic black females and Mexican American males were more overweight or obese compared with non-Hispanic whites.
Also, nearly two-thirds had ideal smoking status (67% males and 70% females). Ideal smoking status was the most prevalent CV health behavior in all sex and race/ethnicity groups, especially among non-Hispanic blacks.
Ideal blood pressure was the most favorable cardiovascular health factor (78% males and 90% females.)
Meanwhile, females had a higher prevalence of ideal blood glucose (89% v. 74% males). Non-Hispanic blacks had the highest prevalence of ideal fasting blood glucose compared with non-Hispanic whites and Mexican Americans. Roughly a quarter of all adolescents had intermediate fasting blood glucose levels.
“Most children are born in a state of ideal cardiovascular health,” Dr. Shay said in an interview. “However, the poor lifestyles many U.S. children exhibit are leading to a loss of this important asset earlier and earlier in life. A stronger focus on emphasizing improvements in adolescent lifestyles needs to be implemented in the clinical setting.”
She added that “significant environmental and cultural changes need to be implemented with the assistance of parents, educators, health professionals, and legislators to promote healthier lifestyles of adolescents (and people of all ages) in order to improve the cardiovascular health of the US adolescent population.”Dr. Shay said her research team is currently comparing the cardiovascular health of the study’s population from 10 years ago to what it is today. “Considering the direction things have been going from then to now, we are estimating what things are going to look like in the year 2020.”
Her team is also working on estimating costs.
The study has several limitations, according to the authors. Although the data are nationally representative, they are cross-sectional and don’t represent temporal changes at an individual level. The data are also insufficient to obtain a confident diagnosis of clinical disease and as a result may underestimate ideal levels of CV health components. Also, the Cardiovascular Health Score does not weight the influence of each individual component, "and should be interpreted in light of this limitation," the authors noted.
They also noted that it is important to consider the fluctuations in health factors – such as increases in total cholesterol levels – that occur naturally during puberty and adolescence. Since NHANES is a cross-section, it does not allow for serial evaluation of CV factors, which could as a result increase the likelihood of misclassification.
The study was supported in part by a grant from the National Heart, Lung, and Blood Institute. None of the authors reported any disclosures except for Dr. Stephen R. Daniels who was the chair of the Data Safety and Monitoring Board for Merck Pharmaceuticals.
On Twitter @naseemsmiller
FROM CIRCULATION
Major Finding: Less than half of adolescents achieved an ideal score in five or more of the seven cardiovascular health components measured in the study. None had ideal levels in all seven categories.
Data Source: Examination of components of cardiovascular health in 4,673 participants between ages 12 and 19 years from the 2005 to 2010 National Health and Nutrition Examination Surveys (NHANES).
Disclosures: The study was supported in part by a grant from the National Heart, Lung, and Blood Institute. None of the authors reported any disclosures except for Dr. Stephen R. Daniels who was the chair of the Data Safety and Monitoring Board for Merck Pharmaceuticals.
Prevent pigment problems in skin of color
MIAMI BEACH – When it comes to procedures such as chemical peels, microdermabrasion, and laser therapies, one size doesn’t fit all, and dermatologists should take special precautions when treating patients with darker skin.
Dr. Marta Rendon, a dermatologist in Boca Raton, Florida, said she sees at least two patients a week who are seeking treatment for pigmentary complications that have been caused by prior cosmetic procedures performed by other physicians.
Some she can treat, and some are beyond repair.
"If I were to sum up my presentation, I would tell you that above all, be conservative and don’t be aggressive," especially in patients with ethnic skin, she told her audience at the annual meeting of the American Academy of Dermatology.
Dr. Rendon, who is also the president of the Skin of Color Society, urged physicians to take precautions because with the increasing diversity of the United States, their patient population is only going to get more diverse.
"Do the patient history. Take your time," advised Dr. Rendon. "Find out what their ethnic background is. Ask them about their grandmother, and where they are from."
The second most important part of history, she said, is asking about reaction to prior procedures or surgeries and prior history of postinflammatory hyperpigmentation (PIH).
"Ask them about what they do, what their hobbies are, or if they play a sport," she said. And take into account the season. During warmer temperatures, consider superficial peels and be careful with lasers. Medium peels and laser resurfacing are more appropriate during cooler and cloudier seasons, she said.
Take caution
Dr. Rendon had the following advice for various procedures in ethnic skin:
• Don’t perform chemical peels on patients on tretinoin. Don’t start with a high concentration. Don’t do excessive layers. And don’t combine surgical procedures with peels in the same visit.
• When performing microdermabrasion, don’t be too aggressive to avoid PIH, streaking, and scratch marks. Don\'t perform the procedure too close to the eyes. Avoid extremely sensitive skin and pressure urticaria. And always start with the lowest strength and time interval.
• With fillers, be careful with superficial placement since the colored material can be seen through the skin. Hyaluronic acid is safer, because it’s colorless and less risky to use. Be mindful that severe bruising can lead to hemosiderin. And be sure that all your patients are using sunscreen.
• For laser and light therapies, always do a test spot. Have a solid understanding of laser-tissue interaction. And be prepared if pigmentation problems develop, so that you can treat them early.
Treatment
Aggressive and early intervention is crucial in treating side effects from cosmetic procedures.
One of the keys to prevent hyperpigmentation is UV protection, whether it’s with sunscreens, cosmetics, antioxidants such as topical vitamin C and E, or systemic agents such as chloroquine, fish oil, or green-tea extract, said Dr. Rendon.
Several topical agents can be used to treat hyperpigmentation. They include hydroquinone, hydroquinone combination, glycolic/retinoid/steroid combination, or antioxidants.
Dr. Rendon also listed several combination bleaching agents including hydroquinone 4%, tretinoin 0.05%, and fluocinolone 0.01%; hydroquinone 4% and retinol 0.3%; hydroquinone microentrapped 4% and retinol 0.15%; hydroquinone and glycolic acid 10%; hydroquinone, glycolic acid 10% + and hyaluronic acid; mequinol and tretinoin 0.01%; retinaldehyde and glycolic acid; and compounded hydroquinone 6%-8%.
Niacinamide is one of the cosmeceutical skin-lightening agents that act as a vitamin exfoliant, reducing melanosome transfer. Soy-protease inhibitors and glutathione also have skin-lightening effects. Dr. Rendon also listed several skin lightening products including Melanozyme, Melaplex, Lumixyl (oligopeptide), retinaldehyde, lactic acid, ferrulic acid, and sunscreen.
She said her favorite method of treating pigmentary complications is to combine treatments. For instance, she combines peels with microdermabrasion; peels with laser; microdermabrasion with IPL; and fractional resurfacing with topical regimens. She added that she maximizes the procedures with topical regimens.
The bottom line is aggressive and early intervention for side effects, Dr. Rendon said.
As a result of growing ethnic population, the treatment options for pigmented skin is expanding, but in the meantime, dermatologists should ensure that their procedures are specific and individualized, Dr. Rendon advised.
"There’s no way of predicting who will hyperpigment, unless you take a good history," she said. And remember two pearls to stay out of trouble: Be conservative, and don’t use aggressive techniques.
Dr. Rendon has performed clinical research for and/or served as a consultant for several companies, including Amgen, Aveeno, Galderma, J&J, Neutrogena, and Sanofi-Aventis. She is a global spokesperson for the H&S brand.
On Twitter @naseemsmiller
MIAMI BEACH – When it comes to procedures such as chemical peels, microdermabrasion, and laser therapies, one size doesn’t fit all, and dermatologists should take special precautions when treating patients with darker skin.
Dr. Marta Rendon, a dermatologist in Boca Raton, Florida, said she sees at least two patients a week who are seeking treatment for pigmentary complications that have been caused by prior cosmetic procedures performed by other physicians.
Some she can treat, and some are beyond repair.
"If I were to sum up my presentation, I would tell you that above all, be conservative and don’t be aggressive," especially in patients with ethnic skin, she told her audience at the annual meeting of the American Academy of Dermatology.
Dr. Rendon, who is also the president of the Skin of Color Society, urged physicians to take precautions because with the increasing diversity of the United States, their patient population is only going to get more diverse.
"Do the patient history. Take your time," advised Dr. Rendon. "Find out what their ethnic background is. Ask them about their grandmother, and where they are from."
The second most important part of history, she said, is asking about reaction to prior procedures or surgeries and prior history of postinflammatory hyperpigmentation (PIH).
"Ask them about what they do, what their hobbies are, or if they play a sport," she said. And take into account the season. During warmer temperatures, consider superficial peels and be careful with lasers. Medium peels and laser resurfacing are more appropriate during cooler and cloudier seasons, she said.
Take caution
Dr. Rendon had the following advice for various procedures in ethnic skin:
• Don’t perform chemical peels on patients on tretinoin. Don’t start with a high concentration. Don’t do excessive layers. And don’t combine surgical procedures with peels in the same visit.
• When performing microdermabrasion, don’t be too aggressive to avoid PIH, streaking, and scratch marks. Don\'t perform the procedure too close to the eyes. Avoid extremely sensitive skin and pressure urticaria. And always start with the lowest strength and time interval.
• With fillers, be careful with superficial placement since the colored material can be seen through the skin. Hyaluronic acid is safer, because it’s colorless and less risky to use. Be mindful that severe bruising can lead to hemosiderin. And be sure that all your patients are using sunscreen.
• For laser and light therapies, always do a test spot. Have a solid understanding of laser-tissue interaction. And be prepared if pigmentation problems develop, so that you can treat them early.
Treatment
Aggressive and early intervention is crucial in treating side effects from cosmetic procedures.
One of the keys to prevent hyperpigmentation is UV protection, whether it’s with sunscreens, cosmetics, antioxidants such as topical vitamin C and E, or systemic agents such as chloroquine, fish oil, or green-tea extract, said Dr. Rendon.
Several topical agents can be used to treat hyperpigmentation. They include hydroquinone, hydroquinone combination, glycolic/retinoid/steroid combination, or antioxidants.
Dr. Rendon also listed several combination bleaching agents including hydroquinone 4%, tretinoin 0.05%, and fluocinolone 0.01%; hydroquinone 4% and retinol 0.3%; hydroquinone microentrapped 4% and retinol 0.15%; hydroquinone and glycolic acid 10%; hydroquinone, glycolic acid 10% + and hyaluronic acid; mequinol and tretinoin 0.01%; retinaldehyde and glycolic acid; and compounded hydroquinone 6%-8%.
Niacinamide is one of the cosmeceutical skin-lightening agents that act as a vitamin exfoliant, reducing melanosome transfer. Soy-protease inhibitors and glutathione also have skin-lightening effects. Dr. Rendon also listed several skin lightening products including Melanozyme, Melaplex, Lumixyl (oligopeptide), retinaldehyde, lactic acid, ferrulic acid, and sunscreen.
She said her favorite method of treating pigmentary complications is to combine treatments. For instance, she combines peels with microdermabrasion; peels with laser; microdermabrasion with IPL; and fractional resurfacing with topical regimens. She added that she maximizes the procedures with topical regimens.
The bottom line is aggressive and early intervention for side effects, Dr. Rendon said.
As a result of growing ethnic population, the treatment options for pigmented skin is expanding, but in the meantime, dermatologists should ensure that their procedures are specific and individualized, Dr. Rendon advised.
"There’s no way of predicting who will hyperpigment, unless you take a good history," she said. And remember two pearls to stay out of trouble: Be conservative, and don’t use aggressive techniques.
Dr. Rendon has performed clinical research for and/or served as a consultant for several companies, including Amgen, Aveeno, Galderma, J&J, Neutrogena, and Sanofi-Aventis. She is a global spokesperson for the H&S brand.
On Twitter @naseemsmiller
MIAMI BEACH – When it comes to procedures such as chemical peels, microdermabrasion, and laser therapies, one size doesn’t fit all, and dermatologists should take special precautions when treating patients with darker skin.
Dr. Marta Rendon, a dermatologist in Boca Raton, Florida, said she sees at least two patients a week who are seeking treatment for pigmentary complications that have been caused by prior cosmetic procedures performed by other physicians.
Some she can treat, and some are beyond repair.
"If I were to sum up my presentation, I would tell you that above all, be conservative and don’t be aggressive," especially in patients with ethnic skin, she told her audience at the annual meeting of the American Academy of Dermatology.
Dr. Rendon, who is also the president of the Skin of Color Society, urged physicians to take precautions because with the increasing diversity of the United States, their patient population is only going to get more diverse.
"Do the patient history. Take your time," advised Dr. Rendon. "Find out what their ethnic background is. Ask them about their grandmother, and where they are from."
The second most important part of history, she said, is asking about reaction to prior procedures or surgeries and prior history of postinflammatory hyperpigmentation (PIH).
"Ask them about what they do, what their hobbies are, or if they play a sport," she said. And take into account the season. During warmer temperatures, consider superficial peels and be careful with lasers. Medium peels and laser resurfacing are more appropriate during cooler and cloudier seasons, she said.
Take caution
Dr. Rendon had the following advice for various procedures in ethnic skin:
• Don’t perform chemical peels on patients on tretinoin. Don’t start with a high concentration. Don’t do excessive layers. And don’t combine surgical procedures with peels in the same visit.
• When performing microdermabrasion, don’t be too aggressive to avoid PIH, streaking, and scratch marks. Don\'t perform the procedure too close to the eyes. Avoid extremely sensitive skin and pressure urticaria. And always start with the lowest strength and time interval.
• With fillers, be careful with superficial placement since the colored material can be seen through the skin. Hyaluronic acid is safer, because it’s colorless and less risky to use. Be mindful that severe bruising can lead to hemosiderin. And be sure that all your patients are using sunscreen.
• For laser and light therapies, always do a test spot. Have a solid understanding of laser-tissue interaction. And be prepared if pigmentation problems develop, so that you can treat them early.
Treatment
Aggressive and early intervention is crucial in treating side effects from cosmetic procedures.
One of the keys to prevent hyperpigmentation is UV protection, whether it’s with sunscreens, cosmetics, antioxidants such as topical vitamin C and E, or systemic agents such as chloroquine, fish oil, or green-tea extract, said Dr. Rendon.
Several topical agents can be used to treat hyperpigmentation. They include hydroquinone, hydroquinone combination, glycolic/retinoid/steroid combination, or antioxidants.
Dr. Rendon also listed several combination bleaching agents including hydroquinone 4%, tretinoin 0.05%, and fluocinolone 0.01%; hydroquinone 4% and retinol 0.3%; hydroquinone microentrapped 4% and retinol 0.15%; hydroquinone and glycolic acid 10%; hydroquinone, glycolic acid 10% + and hyaluronic acid; mequinol and tretinoin 0.01%; retinaldehyde and glycolic acid; and compounded hydroquinone 6%-8%.
Niacinamide is one of the cosmeceutical skin-lightening agents that act as a vitamin exfoliant, reducing melanosome transfer. Soy-protease inhibitors and glutathione also have skin-lightening effects. Dr. Rendon also listed several skin lightening products including Melanozyme, Melaplex, Lumixyl (oligopeptide), retinaldehyde, lactic acid, ferrulic acid, and sunscreen.
She said her favorite method of treating pigmentary complications is to combine treatments. For instance, she combines peels with microdermabrasion; peels with laser; microdermabrasion with IPL; and fractional resurfacing with topical regimens. She added that she maximizes the procedures with topical regimens.
The bottom line is aggressive and early intervention for side effects, Dr. Rendon said.
As a result of growing ethnic population, the treatment options for pigmented skin is expanding, but in the meantime, dermatologists should ensure that their procedures are specific and individualized, Dr. Rendon advised.
"There’s no way of predicting who will hyperpigment, unless you take a good history," she said. And remember two pearls to stay out of trouble: Be conservative, and don’t use aggressive techniques.
Dr. Rendon has performed clinical research for and/or served as a consultant for several companies, including Amgen, Aveeno, Galderma, J&J, Neutrogena, and Sanofi-Aventis. She is a global spokesperson for the H&S brand.
On Twitter @naseemsmiller
EXPERT ANALYSIS FROM THE AAD ANNUAL MEETING
MVAC plus cystectomy boosts bladder cancer survival
ORLANDO – Cisplatin-based neoadjuvant chemotherapy plus cystectomy improved the overall survival of patients with muscle-invasive bladder cancer beyond that achieved with cystectomy alone; however, the results did not reach statistical significance in the Japan Clinical Oncology Group Study, JCOG0209.
In a randomized trial of 130 patients accrued over a 6-year period, overall survival at 5 years was 72.3% for patients who had two cycles of chemotherapy followed by radical cystectomy and 62.4% for patients who had radical cystectomy alone. The overall survival results were not significant because of insufficient sample size, according to Dr. Hiroshi Kitamura of Sapporo (Japan) Medical University.
Median progression-free survival time, however, was significantly longer at 99 months in the group who received neoadjuvant chemotherapy plus cystectomy compared with 78 months in those who had radical cystectomy alone (HR = 0.61, P = .04). Progression-free survival at 5 years was 69.1% and 56.4%, respectively.
The Japan Clinical Oncology Group Study, JCOG0209, examined the MVAC regimen of methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin followed by radical cystectomy. MVAC comprised methotrexate (30 mg/m2) on days 1, 15, and 22; vinblastine (3 mg/m2) on days 2, 15, and 22; Adriamycin (30 mg/m2) on day 2; and cisplatin (70 mg/m2) on day 2.
Because neoadjuvant therapy with gemcitabine and cisplatin is now widely used to treat invasive bladder cancer, and considered to provide a 5%-8% overall survival advantage, the Data and Safety Monitoring Committee recommended early publication of the results, Dr. Kitamura said at the annual Genitourinary Cancers Symposium sponsored by the American Society of Clinical Oncology. The findings indicate that the MVAC regimen can still be considered promising.
"Although (the chemotherapy regimen) was two cycles, and the study was underpowered," chemotherapy plus radical cystectomy were confirmed as the standard of care for muscle-invasive bladder cancer, commented Dr. Dean Bajorin of Memorial Sloan-Kettering Cancer Center, New York, who was not involved in the study. "I do not think we need to include nontreatment arms in these trials anymore."
Between March 2003 and March 2009, researchers randomized 130 patients to receive two cycles of MVAC neoadjuvant chemotherapy followed by radical cystectomy (64 patients) or to radical cystectomy alone (66 patients). Patient registration was terminated early because of slow accrual.
The primary endpoint was overall survival. Secondary endpoints were progression-free survival, surgery-related complication rate, adverse events during neoadjuvant chemotherapy, the rate of no residual tumor in radical cystectomy specimens (pT0), and quality of life.
Results at the second interim analysis showed that overall survival was better with MVAC plus surgery (median, 102 months) than with radical cystectomy alone (median, 81 months), but the difference did not achieve statistical significance because the sample size was small (HR = 0.65, P = .07).
At the time of radical cystectomy, clinical stage was pT0 in 37% of the MVAC arm and 9% in the radical cystectomy arm (P less than .01).
Dr. Kitamura said he had no relationships to disclose. Dr. Bajorin disclosed that he has been a consultant or adviser for Bristol-Myers Squibb, Dendreon, Lilly, and Novartis. He has received honoraria from Lilly, and research funding from Amgen, Dendreon, Genentech, Genta, GlaxoSmithKline, and Novartis.
On Twitter @naseemsmiller
ORLANDO – Cisplatin-based neoadjuvant chemotherapy plus cystectomy improved the overall survival of patients with muscle-invasive bladder cancer beyond that achieved with cystectomy alone; however, the results did not reach statistical significance in the Japan Clinical Oncology Group Study, JCOG0209.
In a randomized trial of 130 patients accrued over a 6-year period, overall survival at 5 years was 72.3% for patients who had two cycles of chemotherapy followed by radical cystectomy and 62.4% for patients who had radical cystectomy alone. The overall survival results were not significant because of insufficient sample size, according to Dr. Hiroshi Kitamura of Sapporo (Japan) Medical University.
Median progression-free survival time, however, was significantly longer at 99 months in the group who received neoadjuvant chemotherapy plus cystectomy compared with 78 months in those who had radical cystectomy alone (HR = 0.61, P = .04). Progression-free survival at 5 years was 69.1% and 56.4%, respectively.
The Japan Clinical Oncology Group Study, JCOG0209, examined the MVAC regimen of methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin followed by radical cystectomy. MVAC comprised methotrexate (30 mg/m2) on days 1, 15, and 22; vinblastine (3 mg/m2) on days 2, 15, and 22; Adriamycin (30 mg/m2) on day 2; and cisplatin (70 mg/m2) on day 2.
Because neoadjuvant therapy with gemcitabine and cisplatin is now widely used to treat invasive bladder cancer, and considered to provide a 5%-8% overall survival advantage, the Data and Safety Monitoring Committee recommended early publication of the results, Dr. Kitamura said at the annual Genitourinary Cancers Symposium sponsored by the American Society of Clinical Oncology. The findings indicate that the MVAC regimen can still be considered promising.
"Although (the chemotherapy regimen) was two cycles, and the study was underpowered," chemotherapy plus radical cystectomy were confirmed as the standard of care for muscle-invasive bladder cancer, commented Dr. Dean Bajorin of Memorial Sloan-Kettering Cancer Center, New York, who was not involved in the study. "I do not think we need to include nontreatment arms in these trials anymore."
Between March 2003 and March 2009, researchers randomized 130 patients to receive two cycles of MVAC neoadjuvant chemotherapy followed by radical cystectomy (64 patients) or to radical cystectomy alone (66 patients). Patient registration was terminated early because of slow accrual.
The primary endpoint was overall survival. Secondary endpoints were progression-free survival, surgery-related complication rate, adverse events during neoadjuvant chemotherapy, the rate of no residual tumor in radical cystectomy specimens (pT0), and quality of life.
Results at the second interim analysis showed that overall survival was better with MVAC plus surgery (median, 102 months) than with radical cystectomy alone (median, 81 months), but the difference did not achieve statistical significance because the sample size was small (HR = 0.65, P = .07).
At the time of radical cystectomy, clinical stage was pT0 in 37% of the MVAC arm and 9% in the radical cystectomy arm (P less than .01).
Dr. Kitamura said he had no relationships to disclose. Dr. Bajorin disclosed that he has been a consultant or adviser for Bristol-Myers Squibb, Dendreon, Lilly, and Novartis. He has received honoraria from Lilly, and research funding from Amgen, Dendreon, Genentech, Genta, GlaxoSmithKline, and Novartis.
On Twitter @naseemsmiller
ORLANDO – Cisplatin-based neoadjuvant chemotherapy plus cystectomy improved the overall survival of patients with muscle-invasive bladder cancer beyond that achieved with cystectomy alone; however, the results did not reach statistical significance in the Japan Clinical Oncology Group Study, JCOG0209.
In a randomized trial of 130 patients accrued over a 6-year period, overall survival at 5 years was 72.3% for patients who had two cycles of chemotherapy followed by radical cystectomy and 62.4% for patients who had radical cystectomy alone. The overall survival results were not significant because of insufficient sample size, according to Dr. Hiroshi Kitamura of Sapporo (Japan) Medical University.
Median progression-free survival time, however, was significantly longer at 99 months in the group who received neoadjuvant chemotherapy plus cystectomy compared with 78 months in those who had radical cystectomy alone (HR = 0.61, P = .04). Progression-free survival at 5 years was 69.1% and 56.4%, respectively.
The Japan Clinical Oncology Group Study, JCOG0209, examined the MVAC regimen of methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin followed by radical cystectomy. MVAC comprised methotrexate (30 mg/m2) on days 1, 15, and 22; vinblastine (3 mg/m2) on days 2, 15, and 22; Adriamycin (30 mg/m2) on day 2; and cisplatin (70 mg/m2) on day 2.
Because neoadjuvant therapy with gemcitabine and cisplatin is now widely used to treat invasive bladder cancer, and considered to provide a 5%-8% overall survival advantage, the Data and Safety Monitoring Committee recommended early publication of the results, Dr. Kitamura said at the annual Genitourinary Cancers Symposium sponsored by the American Society of Clinical Oncology. The findings indicate that the MVAC regimen can still be considered promising.
"Although (the chemotherapy regimen) was two cycles, and the study was underpowered," chemotherapy plus radical cystectomy were confirmed as the standard of care for muscle-invasive bladder cancer, commented Dr. Dean Bajorin of Memorial Sloan-Kettering Cancer Center, New York, who was not involved in the study. "I do not think we need to include nontreatment arms in these trials anymore."
Between March 2003 and March 2009, researchers randomized 130 patients to receive two cycles of MVAC neoadjuvant chemotherapy followed by radical cystectomy (64 patients) or to radical cystectomy alone (66 patients). Patient registration was terminated early because of slow accrual.
The primary endpoint was overall survival. Secondary endpoints were progression-free survival, surgery-related complication rate, adverse events during neoadjuvant chemotherapy, the rate of no residual tumor in radical cystectomy specimens (pT0), and quality of life.
Results at the second interim analysis showed that overall survival was better with MVAC plus surgery (median, 102 months) than with radical cystectomy alone (median, 81 months), but the difference did not achieve statistical significance because the sample size was small (HR = 0.65, P = .07).
At the time of radical cystectomy, clinical stage was pT0 in 37% of the MVAC arm and 9% in the radical cystectomy arm (P less than .01).
Dr. Kitamura said he had no relationships to disclose. Dr. Bajorin disclosed that he has been a consultant or adviser for Bristol-Myers Squibb, Dendreon, Lilly, and Novartis. He has received honoraria from Lilly, and research funding from Amgen, Dendreon, Genentech, Genta, GlaxoSmithKline, and Novartis.
On Twitter @naseemsmiller
AT ASCO GENITOURINARY CANCERS SYMPOSIUM
Major finding: Overall survival was better with MVAC plus radical cystectomy (median, 102 months) than with radical cystectomy alone, (median, 81 months), but the difference did not achieve statistical significance because the sample size was small (HR = 0.65, P = .07).
Data source: A study of 130 patients randomized to receive two cycles of MVAC neoadjuvant chemotherapy followed by radical cystectomy (64 patients), or radical cystectomy alone (66).
Disclosures: Dr. Kitamura said he had no relationships to disclose. Dr. Bajorin disclosed that he has been a consultant or adviser for Bristol-Myers Squibb, Dendreon, Lilly, and Novartis. He has received honoraria from Lilly, and research funding from Amgen, Dendreon, Genentech, Genta, GlaxoSmithKline, and Novartis.